Office of Human Resources
Benefits / Leaves
Post Office Box 751
Portland, Oregon 97207-0751
503-725-4926 tel
503-725-5896 fax
askhrc@pdx.edu
www.pdx.edu/hr
Certification for Serious Injury or Illness
Of Covered Servicemember
For Military Family Leave
(Family and Medical Leave Act)
Federal Form WH-385
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for
whom the Employee Is Requesting Leave
INSTRUCTIONS to the EMPLOYEE or COVERED SERVICEMEMBER: Please complete Section I before having Section II
completed. The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient
certification to support a request for FMLA leave due to a serious injury or illness of a covered servicemember. If requested
by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. §§ 2613, 2614
(c)(3). Failure to do so may result in a denial of an employee’s FMLA request. 29 C.F.R. § 825.310(f). The employer must
give an employee at least 15 calendar days to return this form to the employer.
PART A: EMPLOYEE INFORMATION
Name and Address of Employer (this is the employer of the employee requesting leave to care for covered
servicemember): Portland State University Office of Human Resources Post Office Box 751 Portland, Oregon 97207-0751
Name of Employee Requesting Leave to Care for a Covered Servicemember:
First
Middle
Last
Name of Covered Servicemember (for whom employee is requesting leave to care):
Middle
First
Last
Relationship of Employee to Covered Servicemember Requesting Leave to Care:
Spouse
Parent
Son
Daughter
Next of Kin
PART B: COVERED SERVICEMEMBER INFORMATION
(1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or
Reserves?
If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:
Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to
a unit established for the purpose of providing command and control of members of the Armed Forces
receiving medical care as outpatients (such as a medical hold or warrior transition unit)?
If yes, please provide the name of the medical treatment facility or unit:
(2) Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)?
Yes
No
Yes
No
Yes
No
PART C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER
Describe Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide the Care:
Updated 6/30/2010 – Benefits / Leaves – Federal Form WH-385
Page 1 of 3
SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”)
HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United
States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE
network authorized private health care provider; or (3) a DOD non-network TRICARE
authorized private health care provider
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the FMLA
to care for a family member who is a member of the Regular Armed Forces, the National Guard, or the Reserves who is
undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary
disability retired list for a serious injury or illness. For purposes of FMLA leave, a serious injury or illness is one that was
incurred in the line of duty on active duty that may render the servicemember medically unfit to perform the duties of his or
her office, grade, rank, or rating.
A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s serious injury
or illness includes written documentation confirming that the covered servicemember’s injury or illness was incurred in the
line of duty on active duty and that the covered servicemember is undergoing treatment for such injury or illness by a
health care provider listed above. Answer, fully and completely, all applicable parts. Several questions seek a response as to the
frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical
knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or
“indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the
employee is seeking leave.
PART A: HEALTH CARE PROVIDER INFORMATION
Health Care Provider’s Name and Business Address:
Type of Practice / Medical Specialty:
Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider;
(3) a DOD TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized
private health care provider:
Telephone:
Fax:
Email:
PART B: MEDICAL STATUS
(1) Covered Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):
(VSI) Very Seriously Ill/Injured - Illness/Injury is of such a severity that life is imminently endangered. Family
members are requested at bedside immediately. (Please note this is an internal DOD casualty assistance designation
used by DOD healthcare providers.)
(SI) Seriously Ill/Injured - Illness/injury is of such severity that there is cause for immediate concern, but there is
no imminent danger to life. Family members are requested at bedside. (Please note this is an internal DOD casualty
assistance designation used by DOD healthcare providers.)
OTHER Ill/Injured - a serious injury or illness that may render the servicemember medically unfit to perform the
duties of the member’s office, grade, rank, or rating.
NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take leave to care for a
covered family member with a “serious health condition” under § 825.113 of the FMLA. If such leave is requested,
you may be required to complete DOL FORM WH-380 or an employer-provided form seeking the same information.)
(2)
Was the condition for which the Covered Service member is being treated incurred in line of duty
on active duty in the armed forces?
(3)
Approximate date condition commenced:
(4)
Probable duration of condition and/or need for care:
(5)
Is this covered servicemember undergoing medical treatment, recuperation, or therapy?:
If yes, please describe medical treatment, recuperation or therapy:
Updated 6/30/2010 – Benefits / Leaves – Federal Form WH-385
Yes
No
Yes
No
Page 2 of 3
PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1)
Will the covered servicemember need care for a single continuous period of time, including any
Time for treatment and recovery?
Yes
No
Yes
No
If yes, estimate the beginning and ending dates for this period of time:
(2)
Will the covered servicemember require periodic follow-up treatment appointments?:
If yes, estimate the treatment schedule:
(3)
Is there a medical necessity for the covered servicemember to have periodic care for these
follow-up treatment appointments?
Yes
No
(4)
Is there a medical necessity for the covered servicemember to have periodic care for other than
Scheduled follow-up treatment appointments (e.g., episodic flare-ups of medical condition)?
Yes
No
If yes, please estimate the frequency and duration of the periodic care:
Signature of Health Care Provider
Date
PAPERWORK REDUCTION ACT NOTIVE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. §
825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The
Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection
information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of
Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.
Updated 6/30/2010 – Benefits / Leaves – Federal Form WH-385
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